What is the treatment for Surfer's myelopathy?

Treatment for Surfer's Myelopathy

The treatment for surfer's myelopathy primarily involves high-dose corticosteroids (methylprednisolone) as the first-line intervention, followed by comprehensive rehabilitation, though evidence for specific treatments remains limited due to the rarity of the condition.

Understanding Surfer's Myelopathy

Surfer's myelopathy is a rare, non-traumatic spinal cord injury that primarily affects novice surfers but can also occur during other activities involving hyperextension of the back such as gymnastics, yoga, and Pilates 1. The condition is characterized by:

• Acute onset of back pain
• Rapidly progressive lower extremity weakness or paralysis
• Sensory changes/loss below the level of injury
• Urinary retention and bowel dysfunction
• Typically affects the thoracic spinal cord and conus medullaris

Pathophysiology

The most widely accepted theory regarding the etiology of surfer's myelopathy is vascular insufficiency:

• Hyperextension of the spine during activities like surfing leads to dynamic compression of spinal vasculature, particularly the artery of Adamkiewicz 2, 1
• The Valsalva maneuver performed while attempting to stand on a surfboard increases intraspinal pressure, further compromising blood flow 1
• This results in ischemic injury to the spinal cord, primarily affecting the thoracic region and conus medullaris

Diagnostic Evaluation

1. MRI of the spine with and without contrast:

   • T2-weighted images typically show increased signal in the central spinal cord within 24-72 hours 2
   • Diffusion-weighted imaging may show restricted diffusion from T6 to the conus level 3
   • Rule out compressive lesions

2. Additional testing:

   • Cerebrospinal fluid analysis to rule out infectious causes
   • Vasculitis/paraneoplastic screening to exclude other etiologies

Treatment Approach

Acute Management

1. High-dose corticosteroids:

   • Methylprednisolone (1g daily for 3-5 days) is the most commonly used intervention 4, 3
   • Patients receiving steroids showed improvement in 55% of cases with no reported adverse effects 2
   • Should be initiated as soon as possible after diagnosis

2. Supportive care:

   • Maintain adequate spinal cord perfusion
   • Monitor for respiratory compromise, especially with high cervical involvement
   • Bladder catheterization for urinary retention
   • Bowel management program

Rehabilitation Phase

1. Comprehensive rehabilitation program:

   • Physical therapy focusing on mobility, transfers, and strengthening
   • Occupational therapy for activities of daily living
   • Training for wheelchair mobility if needed

2. Management of complications:

   • Neuropathic pain management with gabapentin, pregabalin, or duloxetine 4
   • Treatment of heterotopic ossification if it develops (as seen in some cases with zolendronic acid) 3
   • Neurogenic bladder management with intermittent self-catheterization
   • Bowel management with transanal irrigation systems

Prognosis

Prognosis is largely determined by the severity of the initial presentation:

• Incomplete cases (some preserved motor or sensory function) often show improvement within 24 hours of onset 2
• Complete cases (American Spinal Injury Association class A) have shown minimal to no neurological recovery 2
• Overall neurological recovery rate is approximately 42% 2

Important Considerations

• Early diagnosis and treatment are crucial for maximizing potential recovery
• Patients with incomplete injuries have a better prognosis than those with complete injuries
• Even without neurological recovery, patients can achieve independence in activities of daily living with appropriate rehabilitation 3
• Prevention through education of novice surfers and instructors about this condition is important 3

Prevention

• Education of novice surfers about proper technique and the risks of hyperextension
• Awareness among instructors to recognize early symptoms
• Consideration of risk factors before engaging in activities with prolonged spine hyperextension

While surfer's myelopathy is rare, prompt recognition and treatment with high-dose corticosteroids, followed by comprehensive rehabilitation, offers the best chance for recovery and functional independence.